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Table of contents
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Document 1 of 1

Effects of Prone Positioning on Lung Protection in Patients with Acute

Respiratory Distress Syndrome
Author: Cornejo, Rodrigo A; Daz, Juan C; Tobar, Eduardo A; Bruhn, Alejandro R; Ramos, Cristobal
A; Gonzlez, Roberto A; Repetto, Claudia A; Romero, Carlos M; Glvez, Luis R; Llanos, Osvaldo;
Arellano, Daniel H; Neira, Wilson R; Daz, Gonzalo A; Zamorano, Anbal J; Pereira, Gonzalo L
ProQuest document link
Abstract: Positive end-expiratory pressure (PEEP) and prone positioning may induce lung
recruitment and affect alveolar dynamics in acute respiratory distress syndrome (ARDS). Whether
there is interdependence between the effects of PEEP and prone positioning on these variables is
unknown.
To determine the effects of high PEEP and prone positioning on lung recruitment, cyclic
recruitment/derecruitment, and tidal hyperinflation and how these effects are influenced by lung
recruitability.
Mechanically ventilated patients (Vt 6 ml/kg ideal body weight) underwent whole-lung computed
tomography (CT) during breath-holding sessions at airway pressures of 5, 15, and 45 cm H2O and
Cine-CTs on a fixed thoracic transverse slice at PEEP 5 and 15 cm H2O. CT images were repeated
in supine and prone positioning. A recruitment maneuver at 45 cm H2O was performed before
each PEEP change. Lung recruitability was defined as the difference in percentage of nonaerated
tissue between 5 and 45 cm H2O. Cyclic recruitment/de-recruitment and tidal hyperinflation were
determined as tidal changes in percentage of nonaerated and hyperinflated tissue, respectively.
Twenty-four patients with ARDS were included. Increasing PEEP from 5 to 15 cm H2O decreased
nonaerated tissue (501 201 to 322 132 grams; P <0.001) and increased tidal-hyperinflation
(0.41 0.26 to 0.57 0.30%; P = 0.004) in supine. Prone positioning further decreased
nonaerated tissue (322 132 to 290 141 grams; P = 0.028) and reduced tidal hyperinflation
observed at PEEP 15 in supine patients (0.57 0.30 to 0.41 0.22%). Cyclic recruitment/derecruitment only decreased when high PEEP and prone positioning were applied together (4.1
1.9 to 2.9 0.9%; P = 0.003), particularly in patients with high lung recruitability.
Prone positioning enhances lung recruitment and decreases alveolar instability and hyperinflation
observed at high PEEP in patients with ARDS.

Full text: Headnote

Rationale: Positive end-expiratory pressure (PEEP) and prone positioning may induce lung
recruitment and affect alveolar dynamics in acute respiratory distress syndrome (ARDS). Whether
there is interdependence between the effects of PEEP and prone positioning on these variables is
unknown.
Objectives: To determine the effects of high PEEP and prone positioning on lung recruitment,
cyclic recruitment/derecruitment, and tidal hyperinflation and how these effects are influenced by
lung recruitability.
Methods: Mechanically ventilated patients (VT 6 ml/kg ideal body weight) underwent whole-lung
computed tomography (CT) during breath-holding sessions at airway pressures of 5, 15, and 45
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cm H2O and Cine-CTs on a fixed thoracic transverse slice at PEEP 5 and 15 cm H2O. CT images
were repeated in supine and prone positioning. A recruitment maneuver at 45 cm H2O was
performed before each PEEP change. Lung recruitability was defined as the difference in
percentage of nonaerated tissue between 5 and 45 cm H2O. Cyclic recruitment/derecruitment and
tidal hyperinflation were determined as tidal changes in percentage of nonaerated and
hyperinflated tissue, respectively
Measurements and Main Results: Twenty-four patients with ARDS were included. Increasing PEEP
from 5 to 15 cmH2Odecreased nonaerated tissue (501 6 201 to 322 6 132 grams; P , 0.001) and
increased tidal-hyperinflation (0.416 0.26 to 0.57 6 0.30%; P 14 0.004) in supine.Prone positioning
further decreasednonaeratedtissue (322 6132 to2906141 grams; P140.028) andreduced tidal
hyperinflation observed at PEEP 15 in supine patients (0.5760.30 to 0.4160.22%). Cyclic
recruitment/derecruitmentonlydecreasedwhenhighPEEPand prone positioningwere applied
together (4.161.9 to 2.960.9%; P14 0.003), particularly in patients with high lung recruitability.
Conclusions: Prone positioning enhances lung recruitment and decreases alveolar instability and
hyperinflation observed at high PEEP in patients with ARDS.
Ventilator-induced lung injury (VILI) seems to play an important role in patients with acute
respiratory distress syndrome (ARDS) (1). The mechanisms by which mechanical ventilation
exerts its detrimental effect are not completely understood, but it appears that hyperinflation of
lung units and shear forces generated during cyclic recruitment/derecruitment of unstable alveoli
exacerbate, or even initiate, lung injury (1).
High levels of positive end-expiratory pressure (PEEP) and prone positioning have been
demonstrated to reduce VILI in experimental models of acute lung injury (ALI) (2-5). However,
analysis of several large clinical trials in patients with ALI or ARDS suggests that these
interventions may be effective only in patients with severe ARDS (6-9). Patients who seem to
benefit from prone positioning are frequently subjected to higher levels of PEEP. Thus, there may
be a potential interaction between the effects of both interventions on the mechanisms of VILI.
Regarding VILI, PEEP may have a protective effect by favoring lung recruitment and by reducing
cyclic recruitment/ derecruitment (1, 6), but other mechanisms (e.g., redistribution of
extravascular lung water, redistribution of pulmonary blood flow to better aerated units, or
preservation of surfactant activity) may be involved. However, PEEP may induce hyperinflation
and increase the risk of VILI, especially in patients with low recruitability or lobar ARDS (10-12). In
fact, some patients exhibit tidal hyperinflation despite using low VT and moderate PEEP levels
according to the ARDS-Net strategy (13, 14).
Prone positioning may influence mechanisms of VILI. By recruiting nonaerated tissue and by
reducing the vertical pleural pressure gradient, prone positioning may provide a more uniform
distribution of transpulmonary pressures during mechanical ventilation (15-21). Therefore, prone
positioning may act synergistically with high PEEP to protect the lungs from VILI by enhancing
lung recruitment and decreasing the risk of PEEP-induced hyperinflation.
The objectives of this study were to determine the combined effects of high PEEP and prone
positioning on lung recruitment, cyclic recruitment/derecruitment, and tidal hyperinflation, as
assessed by static and dynamic computed tomography (CT) in patients with ARDS. In addition, we
sought to determine whether these responses are influenced by lung recruitability (22). Some of
the results of this study have been previously reported in the form of abstracts (23, 24).
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METHODS
Study Population
Twenty-four patients were studied in a university hospital. Institutional and governmental ethical
committees granted their approval. Informed consent was obtained from the patients' next of kin.
Adult patients fulfilling ARDS criteria (25) and on mechanical ventilation for 24 to 72 hours who
required lung CT scan for clinical purposes were enrolled. Patients younger than 18 years of age,
who were pregnant, or for whom prone positioning was contraindicated (26) were excluded.
Study Protocol
Patients were evaluated in the ICU and CT room (Figure 1). During the protocol they were kept
under deep sedation and neuromuscular paralysis and ventilated in volume-controlled mode with
VT of 6 ml/kg ideal body weight.
ICU Assessments
Patients were ventilated with PEEP 5 and 15 cm H2O, for 20 minutes each, in supine and prone
positions (PEEP changes and positioning were applied in random order). Respiratory mechanics,
oxygenation, and hemodynamic parameters were assessed at the end of each setting.
Before PEEP changes, a recruitment maneuver at 45 cm H2O airway pressure was performed to
standardize volume history. Quasistatic compliance of the respiratory system ("compliance") was
calculated by dividing VT by the difference between plateau pressure and total PEEP.
CT Assessments
Patients underwent whole-lung CT during breath-holding sessions at three different airway
pressures: 45 cm H2O end-inspiratory airway pressure and at 5 and 15 cm H2O PEEP. CT scanning
(Somaton Sensation, Siemens, Germany) was performed under the following protocol: voltage 120
kVp, current 200 mA, mAs 100, rotation time 0.5 seconds, matrix 512 3 512. Lung compartments
were defined according to their CT density in hyperinflated (2901 to 21,000 Hounsfield units
[HU]), well aerated (2501 to 2900 HU), poorly aerated (2101 to -500 HU), and nonaerated tissue
(2100 to 1100 HU) (22). Lung weight for each compartment was calculated as 1 2 (mean CT
number/21,000) 3 volume, where CT number represents lung density (HU). Percentage of
potentially recruitable lung was defined as (nonaerated tissue at 5 cmH2O 2 nonaerated tissue at
45 cm H2O)/total weight and high lung recruitability as a percentage of potentially recruitable
lung greater than 13.9% in supine, which corresponds to the median value observed in 49
patients with ARDS in a previous study of lung recruitability (22). Contiguous axial sections (5 mm
thick) were reconstructed from the volumetric data using a high-definition filter.
A 2.4-mm-thick supradiaphragmatic CT slice was selected for dynamic CT. Respiratory rate was
transiently decreased to 10 breaths per minutes during dynamic CT capture. Cine-CTs of 12
seconds were performed under the following protocol: voltage 100 kVp, current 80 mA, mAs 40;
rotation time 0.5 seconds, 24 images; matrix 512 3 512. Lung compartments were expressed as
percentage of tissue weight in the transverse slice. Cyclic recruitment/derecruitment and tidal
hyperinflation were determined as tidal changes in percentage of nonaerated and hyperinflated
tissue, respectively.
CT images were repeated in supine and prone positioning, and the sequence of positions and
PEEP levels was applied in random order. Images were analyzed manually by radiologists using
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Pulmo (Siemens, Germany) and MALUNA (University of Gottingen, Germany) software. Further
details are provided in the online supplement.
Statistical Analysis
Results are expressed as mean (6 SD) or median (interquartile range). The effect of PEEP level
and position was assessed by applying a twoway ANOVA for repeated measurements with Sidak's
post hoc analysis. Comparisons between patients with low and high lung recruitability were
performed with Student's t test or Wilcoxon Mann-Whitney test. SPSS 20.0 software (Chicago, IL)
was used for statistical calculations. Twosided P , 0.05 was considered statistically significant.
RESULTS
We included 24 patients (15 male; 54 6 18 yr of age) with ARDS. Fourteen patients presented with
patchy, six with diffuse, and four with lobar CT attenuations. Baseline characteristics are
presented in Table 1.
Prone positioning had no significant effect on gas exchange or compliance when compared with
supine position at PEEP 5 (Table 2). However, it induced a decrease in nonaerated tissue and an
increase in well aerated tissue (Table 3).
Increasing PEEP from 5 to 15 cm H2O increased oxygenation and compliance (Table 2), decreased
nonaerated tissue, and increased well aerated tissue (Table 3). However, it markedly increased
hyperinflation. These effects were observed at supine and prone positioning. Nevertheless,
compared with supine, at prone positioning oxygenation and compliance tended to be higher at
PEEP 15, whereas nonaerated tissue and hyperinflation were lower (Table 3; Figure 2).
The effects of prone positioning and PEEP level on determinants of VILI, namely cyclic recruitment
and derecruitment and tidal hyperinflation, are shown in Figure 3. Compared with supine position
at PEEP 5, neither prone positioning nor increasing PEEP had a significant effect on cyclic
recruitment and derecruitment. However, both strategies applied together (prone positioning at
PEEP 15) significantly decreased cyclic recruitment and derecruitment (4.1 6 1.9 to 2.9 6 0.9%; P
14 0.003). Tidal hyperinflation was not affected by prone positioning at PEEP 5, but it increased in
response to PEEP 15 in supine positioning (0.41 6 0.26 to 0.57 6 0.30%; P 14 0.004). The PEEPinduced tidal hyperinflation observed in supine positioning was markedly decreased by prone
positioning (0.57 6 0.30 to 0.41 6 0.22%; P 14 0.01).
Potentially recruitable lung was 18.3 6 11% in supine positioning and 14.9 6 8% in prone
positioning (P 14 0.036). Figure 4 shows CT images from representative patients obtained at
airway pressures of 5 and 45 cm H2O in supine and prone positioning. According to our predefined
threshold, 14 patients had high lung recruitability.
Increasing PEEP to 15 cm H2O improved oxygenation and compliance only in patients with high
lung recruitability. This subgroup exhibited a 48% relative decrease in nonaerated tissue when
increasing PEEP; this effect was seen in only 22% of patients with low lung recruitability (Table 4).
In contrast to patients with high lung recruitability who showed no additional effect of prone
positioning on nonaerated tissue at PEEP 15, patients with low lung recruitability exhibited a
significant decrease in nonaerated tissue when subjected to prone positioning (20% additional
relative decrease).
Cyclic recruitment/derecruitment was significantly lower at baseline in patients with low lung
recruitability (2.8 6 1.3% vs. 5.1 6 1.8% in patients with high lung recruitability; P 14 0.002), and
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neither increasing PEEP nor prone positioning had a significant effect on this variable in the
former subgroup (Figure 3). In contrast, cyclic recruitment and derecruitment decreased in
patients with high lung recruitability when increasing PEEP to 15 cm H2O, and a significant
additional effect was obtained after prone positioning at the same PEEP level. Regarding tidal
hyperinflation, patients with low and high lung recruitability had similar values at baseline (0.39 6
0.25% vs. 0.45 6 0.24; P 14 0.568). The effect of high PEEP level on increasing tidal hyperinflation
was prevented by prone positioning in both subgroups of lung recruitability.
DISCUSSION
The main finding of the present study is that prone positioning enhances the effects of high PEEP
on lung recruitment and cyclic recruitment/derecruitment, whereas it prevents the effects of high
PEEP on tidal hyperinflation. In addition, we found that lung recruitability, assessed by CT at high
airway pressures (22), does not predict lung recruitment induced by prone positioning.
Effects of Prone Positioning
Although it has been reported that oxygenation improves after prone positioning (7-9), we only
found a trend that did not reach statistical significance. This may be explained by the short
sampling period. Data obtained from different series of prolonged prone positioning in patients
with ARDS found that oxygenation improves several hours after prone positioning begins (26-30).
Another possible explanation is that oxygenation variation and lung recruitment may be
dissociated because "anatomical" lung recruitment may differ from "functional" recruitment (22).
We observed that prone positioning was an effective recruitment strategy that, in contrast to high
PEEP, did not increase hyperinflated tissue or plateau pressures. This effect may be explained in
part by the suppression of the compressive force of the heart on dorsal lung regions caused by
prone positioning (31, 32). Patients with predominantly basal consolidations, such as patients A
and B from Figure 4, were those who experienced higher recruitment induced by prone positioning
(data not shown), which is in line with the findings of Galiatsu and colleagues (15). These
observations may complement the concept by Rouby and colleagues about lung morphology as a
predictor of the response to increasing airway pressures (33), although this requires confirmation
by further studies.
In patients with low potentially recruitable lung, prone positioning was able to recruit a significant
amount of nonaerated tissue in addition to that already recruited by high PEEP (Table 4).
Therefore, the assessment of potentially recruitable lung between 5 to 45 cm H2O may correctly
predict lung recruitability to increasing airway pressures but not the response to prone. Thus,
prone positioning may be considered in patients with severe ARDS even if they have poor
response to recruitment maneuvers in supine position as assessed by CT.
Effects of PEEP
Although increasing PEEP from 5 to 15 cm H2O decreased nonaerated tissue and increased
oxygenation, it had no consistent effect on cyclic recruitment/derecruitment in the overall
population. However, in the subgroup of patients with higher lung recruitability, cyclic
recruitment/derecruitment significantly decreased when increasing PEEP to 15 cm H2O (Figure 3).
Similar findings were reported in a recent study in which cyclic recruitment/derecruitment was
assessed indirectly with static CT images (34).

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As expected, in supine positioning high PEEP resulted in higher plateau pressures, hyperinflated
tissue, and tidal hyperinflation. Hyperinflation is a morphologic description of the lung areas that
appear overfilled with gas in CT images, and it has been associated with VILI (14). The low values
of tidal hyperinflation may seem irrelevant (,1%). However, fractional analysis of CT data was
based on lung weight instead of volume, so the magnitude of real hyperinflated tissue may have
been systematically underestimated (35, 36). We used weight for fractional analysis in dynamic
CT because total volume is changing throughout the respiratory cycle. If the results were
expressed as percentage of volume, tidal hyperinflation would have been 10 times greater (46%). PEEP-induced tidal hyperinflation could be an important drawback of high PEEP strategies
(14), which may explain the lack of consistency in the results of recent clinical trials (6).
The fact that high PEEP levels could favor hyperinflation without a consistent decrease in cyclic
recruitment/derecruitment supports the notion that PEEP should be titrated individually based not
only on oxygen exchange but also on other variables, such as lung recruitability.
Interaction of Prone Positioning with PEEP
Few studies have addressed the issue of potential interactions between prone positioning and
PEEP (37, 38). In the present study, we found that prone positioning has a synergistic effect with
high PEEP in increasing respiratory system compliance, likely because of an increase in well
aerated lung tissue. Previous studies have shown contradictory data about the effects of prone
positioning on respiratory system compliance (39). These discrepancies may be due to differences
in chest wall compliance and lung recruitability of the study groups.
Prone positioning and high PEEP induced lung recruitment, resulting in the least amount of
nonaerated tissue. Prone positioning also reinforced the effect of high PEEP on cyclic recruitment/
derecruitment, especially in patients with higher lung recruitability. This interaction did not seem
to be a simple additive effect because in the whole population neither prone at low PEEP nor high
PEEP on supine decreased cyclic recruitment/derecruitment. Thus, prone positioning and high
PEEP together showed a synergistic effect on cyclic recruitment/derecruitment.
Prone positioning prevented the increase in hyperinflated tissue and in tidal hyperinflation
induced by high PEEP levels in supine positioning. Likewise, the increase in plateau pressures
induced by high PEEP was lower in prone positioning. These findings may be related to the effects
of prone positioning in decreasing pleural pressure gradients and homogenizing transpulmonary
pressures in the lungs of patients with ARDS (15, 16, 18, 20). A regional analysis of CT images, as
performed by Grasso and colleagues (40), would be a valuable complement to the present study
to assess the effects of prone positioning on inhomogeneity and recruitment of individual lung
regions.
The results of the present study suggest that a high PEEP strategy applied in prone positioning,
instead of supine positioning, could have more beneficial and less adverse effects in terms of
respiratory mechanics and determinants of VILI. These findings are consistent with the
observations of a metaanalysis, which indicate that patients with severe forms of ARDS, who are
usually ventilated with high levels of PEEP, may have a survival benefit when treated in prone
positioning (7-9).
Recruitment and Cyclic Recruitment/Derecruitment: Methodological Issues
CT has been the gold standard to assess lung recruitment, although different definitions have
been applied (10, 41).We chose the original definition of recruitment based on the decrease of
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nonaerated tissue expressed in lung weight as we have used in the past (22, 42) because it may
be applied to analyze cyclic recruitment/derecruitment in dynamic CT. Other authors have defined
recruitment as the reaeration of the nonaerated and poorly aerated compartment (10). Because
we applied a definition limited to the nonaerated compartment, we acknowledge that our results
for PEEP-induced recruitment may appear as subestimated compared with studies that include
the poorly aerated compartment, as shown in a recent study using transthoracic ultrasound (43).
The threshold of 13.9% used in the present study to classify patients as having high or low lung
recruitability in supine position was predefined arbitrarily based on the median value of the
subgroup of 49 patients with ARDS from Gattinoni's study. The original lung recruitability
threshold of Gattinoni's study was 9%, which corresponded to the median value of the whole
ALI/ARDS population (68 patients). By applying a different threshold, our subgroups of higher and
lower lung recruitability are not comparable to the subgroups defined in the original study by
Gattinoni (22).
There is controversy regarding whether cyclic recruitment/ derecruitment, as assessed by CT,
corresponds to intratidal opening and closing of lung units or to flooded alveoli that become
partially inflated during inspiration (44, 45). Whatever the underlying phenomenon (cyclic
mechanical deformation or cyclic recruitment/derecruitment of lung units), a reduction of
instability produced by prone positioning at high PEEP, as supported by our study, appears as
theoretically positive in terms of lung protection.
Several approaches to assess cyclic phenomena have been used (46). A cine-CT analysis of a
fixed transverse slice allows dynamic imaging without mechanical ventilation interruption. This
method has been recently validated by experimental and clinical studies to determine cyclic
recruitment/derecruitment, tidal hyperinflation, and dynamic lung strain (18, 35, 36, 47, 48).
The main limitations of this method are: 1) The more inhomogeneous the lung impairment, the
less representative the slice may be (this handicap is particularly true in patients with lobar
pattern, but only four of our patients had such pattern); 2) It is impossible for dynamic CT to scan
exactly the same anatomical structure in different settings, although the careful definition of
anatomical landmarks and fractional analysis used for dynamic CT may avoid artifacts created by
the cranio-caudal motion; and 3) the absolute amount of grams of lung tissue undergoing
recruitment/derecruitment or tidal hyperinflation cannot be determined. The alternative approach
of using static CT images of the whole lung after end-expiratory and end-inspiratory breath holds
(15, 16, 18-20, 22, 34) also has several limitations, the most important being the time
dependency of the recruitment and derecruitment phenomena (49, 50). Despite the limitations of
both methods, a previous study comparing them showed no major differences (48).
In conclusion, prone positioning induces lung recruitment even in patients classified as having low
potential for lung recruitment. In addition, prone positioning applied together with high PEEP
levels in patients with ARDS act synergistically to decrease mechanical determinants of VILI such
as cyclic recruitment/derecruitment and tidal hyperinflation.
Author disclosures are available with the text of this article at www.atsjournals.org.
Acknowledgment: The authors thank Dr. Jernimo Graf, Dr. Gastn Murias, and Dr. Guillermo
Bugedo for critical comments and suggestions for the manuscript; the nurses, respiratory
therapists, medical staff, and medical technologists from Hospital Clnico Universidad de Chile for
support during the execution of the studies; Dr. Hector Gatica for the statistical advice in the
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present article; Daniel Castro, medical biophysics and radiation protection officer, who assessed
and adjusted the level of radiation per CT, allowing that the total dose per patient did not exceed
the equivalent of one coronary CT angiography study.
Sidebar
AT A GLANCE COMMENTARY
Scientific Knowledge on the Subject
Experimental and clinical studies suggest that high levels of positive end-expiratory pressure
(PEEP) and prone positioning may favor protective mechanical ventilation in patients with acute
respiratory distress syndrome. High PEEP may induce lung recruitment and decrease cyclic
recruitment/derecruitment; however, increasing PEEP may increase hyperinflation. Prone
positioning could have synergistic effects with high PEEP by providing a more uniform recruitment
and better distribution of lung stress.
What This Study Adds to the Field
In ventilated patients with acute respiratory distress syndrome, prone positioning enhances the
effects of high PEEP in terms of lung recruitment and reduction of cyclic
recruitment/derecruitment and prevents the negative impact of PEEP on tidal hyperinflation.
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AuthorAffiliation
Rodrigo A. Cornejo1, Juan C. Daz2, Eduardo A. Tobar1, Alejandro R. Bruhn3, Cristobal A. Ramos2,
Roberto A. Gonzlez1, Claudia A. Repetto1, Carlos M. Romero1, Luis R. Glvez1, Osvaldo Llanos1,
Daniel H. Arellano1, Wilson R. Neira1, Gonzalo A. Daz1, Anbal J. Zamorano1, and Gonzalo L.
Pereira2
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1Unidad de Pacientes Crticos, Departamento de Medicina, Hospital Clnico Universidad de Chile;

2Departamento de Radiologa, Hospital Clnico Universidad de Chile, Santiago, Chile; and
3Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catlica de
Chile, Santiago, Chile
(Received in original form July 23, 2012; accepted in final form January 12, 2013)
This work was supported by FONDECYT grant 11070156, Chile.
Author Contributions: Substantial contributions to conception and design: R.A.C. Acquisition of
data: R.A.C., J.C.D., C.M.R., R.A.G., C. A. Repetto, D.H.A., W.R.N., G.A.D., A.J.Z., G.L.P. Analysis and
interpretation of data: R.A.C., E.A.T., A.R.B., C.M.R., L.R.G., O.L. Drafting the article or revising it
critically for important intellectual content: R.A.C., J.C.D., E.A.T., A.R.B., C.M.R., R.A.G., C. A.
Repetto, C. A. Ramos, L.R.G., O.L., D.H.A., W.R.N., G.A.D., A.J.Z., G.L.P. Final approval of the version
to be published: R.A.C., J.C.D., E.A.T., A.R.B., C.M.R., R.A.G., C. A. Repetto, C. A. Ramos, L.R.G., O.L.,
D.H.A., W.R.N., G.A.D., A.J.Z., G.L.P.
Correspondence and requests for reprints should be addressed to Rodrigo Cornejo, M.D.,
Universidad de Chile, Santos Dumont 999, Independencia, Santiago, Chile. E-mail:
rcornejor@redclinicauchile.cl
This article has an online supplement, which is accessible from this issue's table of contents at
www.atsjournals.org
Am J Respir Crit Care Med Vol 188, Iss. 4, pp 440-448, Aug 15, 2013
Copyright a 2013 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.201207-1279OC on January 24, 2013
Internet address: www.atsjournals.org

MeSH: Adult, Aged, Aged, 80 & over, Female, Humans, Male, Middle Aged, Pulmonary Alveoli -physiology, Tomography, X-Ray Computed, Lung -- radiography (major), Positive-Pressure
Respiration (major), Positive-Pressure Respiration (major) -- methods, Prone Position -- physiology
(major), Respiratory Distress Syndrome, Adult -- physiopathology (major), Respiratory Distress
Syndrome, Adult -- therapy (major)
Publication title: American Journal of Respiratory and Critical Care Medicine
Volume: 188
Issue: 4
Pages: 440-8
Number of pages: 9
Publication year: 2013
Publication date: Aug 15, 2013
Year: 2013
Publisher: American Thoracic Society
Place of publication: New York
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Country of publication: United States

Publication subject: Medical Sciences--Respiratory Diseases
ISSN: 1073449X
Source type: Scholarly Journals
Language of publication: English
Document type: General Information, Journal Article
Accession number: 23348974
ProQuest document ID: 1439258399
Document URL: http://search.proquest.com/docview/1439258399?accountid=38628
Copyright: Copyright American Thoracic Society Aug 15, 2013
Last updated: 2014-02-05
Database: ProQuest Nursing & Allied Health Source

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